Will Republican proposals to replace Obamacare make America healthier?

On June 22, House Republicans announced proposals for a healthcare plan to replace the Affordable Care Act (“Obamacare”). Republicans claim the proposals would slow healthcare spending and ease federal rules for health insurance. Not surprisingly, a varied set of reactions to the proposals came quickly.

Without providing a cost estimate, Speaker Paul D. Ryan of Wisconsin and his Republican colleagues issued a detailed 20,000-word description of the plan. Included is a gradual rise in the eligibility age for Medicare, which is now 65, to 67 and plans to revamp Medicare into “a fully competitive, market-based model known as premium support.” The proposals would have Medicare compete directly with plans from commercial insurers.

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House Republicans also plan to roll back the Affordable Care Act’s expansion of Medicaid and give states the option to receive Medicaid funds in a block grant each year. With this option, states would accept a fixed amount of funding determined by government calculations in exchange for the flexibility to run their Medicaid programs the way they choose.

Under another option, the federal government would offer a “per-capita cap” in which the government would pay its share of a state’s Medicaid costs up to a certain amount per beneficiary. The state would bear 100% of medical costs in excess of that amount. Under these options, states could drastically reshape the program, which provides health insurance to more than 70 million people at a federal cost of more than $350 billion per year.

An important provision of the Affordable Care Act mandates that insurers cannot deny coverage or charge higher premiums because of a person’s medical condition or history. The House Republican guidelines would replace this with more complex, but less stringent standards.

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Republicans also propose to do away with the requirement that most Americans carry health insurance. Instead, they would provide a flat tax credit to each person or family in the individual insurance market, regardless of income or the premium for their insurance plan.

Reaction mixed

“The Republican proposal doesn’t have the stipulation that coverage would be required, and that creates a concern,” says Wanda Filer MD, FAAFP, president of the American Academy of Family Physicians. She adds that both healthcare coverage and a usual source of care are “two things very important to improving the health of the country.”

Next: Putting aside the details

James Capretta, a resident fellow at the American Enterprise Institute, a conservative-leaning Washington think tank, feels that the comprehensiveness of the Republican proposals is an asset.

The Republican plan provides tax credits for people 65 and older or disabled who are on Medicare, low-income households on Medicaid, working people on a health insurance plan from their employer and those working but not getting insurance from their employer. “Between those four structures, everybody in the United States, if they want to enroll in a health insurance plan, should be able to do so affordably,” says Capretta. “I think that’s a very big step.”

Of course, the main focus of healthcare is the patient. Filer says nothing in the GOP plan addresses patients’ struggles with out-of-pocket costs. “When doctors try to prescribe medications, laboratory tests or physical therapy, patients can’t take a medication or get blood work because they can’t afford to pay for them,” she says. “Also, physicians are told that we’ll be graded on quality of care, but it’s hard to get quality when your patients can’t obtain care.”   

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Capretta envisions the Republican plan as a catalyst for significant change. Currently, he says, the Affordable Care Act, lets the government decide the future of physician practices and hospitals through regulations. According to Capretta, the Republican plan undoes much of that and relies instead on a market-based approach where purchasers and consumers-and not the government-decide what is good value in healthcare.

Putting aside the details of the proposal such as health savings accounts, strengthening Medicare Advantage plans and Part D prescription drug coverage, the essential question persists: Will the changes put forth by the GOP help Americans achieve better health and longer lives? Not necessarily, says G. William Hoagland, senior vice president of the Bipartisan Policy Center.

“Some Americans who need health insurance might benefit from options such as expanded tax credits and high-risk pools,”Hoagland told Medical Economics via email. “Others might not benefit from a per capita Medicaid cap or fall between the cracks of private coverage and public coverage as the age for Medicare eligibility increases. Also, removing the requirement that individuals buy health insurance might have a negative effect on the very people who should obtain healthcare coverage.”